Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Wednesday, January 23, 2013

How the "Revolving Door" and Other Aspects of Corporatism Benefited Amgen Just After its Settlement and Guilty Plea

At least here in these United States, our health care corporatism is bipartisan. Here we present a sorry story of how a company that should have been shamed by dishonest behavior that likely harmed patients instead apparently was awarded special treatment through its cozy relationships with top government leaders

Accusations of Kickbacks and Deceptive Marketing of Aranesp

Last month, biotechnology giant pleaded guilty to a charge of misbranding and settled civil charges with the US government for $762 million (look here). Soon after, New York Times article described the unethical practices the company was alleged to have performed. It opened with a vivid anecdote:

'I hope no one is taping this,' the Amgen manager remarked at a company sales meeting in 2005.

The manager then boasted of how she had given a $10,000 unrestricted
grant to a pet project of a doctor who was an adviser to the local Medicare
contractor. In turn, she said, the doctor would help persuade the
contractor to provide reimbursement for an unapproved use of Amgen’s anemia drug, Aranesp.

Since that account appeared to be of a quid pro quo, it did sound like some a kickback or bribery. In addition,

Amgen is also accused of offering kickbacks to doctors and clinics to
induce them to use its drugs. These reportedly came as cash, rebates,
free samples, educational and research grants, dinners and travel, and
other inducements.

Of course, since this was the usual sort of settlement we see of health care corporate wrongdoing, in which the reason the company is paying what appears to be a large fine remains ambiguous,

Except for those in the criminal count, Amgen denied the other
accusations, though it did issue a statement on Wednesday acknowledging
the settlement.

'The government raised important concerns in the criminal prosecution,'
Cynthia M. Patton, chief compliance officer at Amgen, said in the
statement. 'Amgen acknowledges that mistakes were made, and we did not
live up to our standards.'

"Mistakes were made," what a handy phrase to avoid acknowledging that a real person or person made those mistakes. Why government prosecutors did not leverage instances in which the mistakes were made by an identifiable person, for example, the manager in the anecdote above, to find out who ultimately authorized and directed the kickbacks and deceptive marketing, and then seek to indict them is a mystery. The US Department of Justice now seems to be disinclined to ever pursue top health care corporate executives who may have done wrong, while they exuberantly pursue fines from the companies they direct, fines which have almost no personal impact on those who authorized, directed or implemented the bad behavior.

The Times article also included a telling allegation that behind this apparent misbehavior was a changed corporate culture that put short-term revenue ahead of all other considerations.

the corporate culture changed starting around
2000. That was when new management came in and Aranesp was approved,
setting up a fierce marketing battle with Johnson & Johnson and its
rival anemia drug, Procrit.

'It was more important to make your numbers than to follow the rules,'
said [former Amgen sales representative and now whistle-blower Jill] ...Osiecki, who was based in Milwaukee and sold Aranesp.

We have discussed how the "make your numbers" culture seems to have resulted from an over-generalization of the prevalent belief in business schools that "maximizing shareholder value," which usually seems to mean maximizing short-term revenue and/or doing whatever it takes to boost stock prices in the short-term (look here). In companies which make potentially beneficial but also potentially hazardous drugs, the risks of "make your numbers" are obvious.

Shameful Consequences for Patients

These were disconcerting revelations. They showed that some unidentified employees, probably including top leaders of a major health care corporation seemed to use kickbacks and lies to deceptively market a drug just to "make their numbers," and thus most likely score healthy bonuses. Yet this drug is clearly dangerous. The official Aranesp label states (in a black box warning, in capital letters):

Thus deceptive and unethical marketing practices likely lead to overuse of the drug, and overuse of the drug likely lead to sick (via myocardial infarction [heart attack], stroke, venous thromboembolism or thrombosis of vascular access [drug clots], or tumor progression) or dead patients.

One would think that the consequences of the particular bad behavior alleged in this case would have lead to more zealous prosecution and to the pursuit of actual people who authorized, directed or implemented the bad behavior. However, it did not.

One would also think that the nature and consequences of this bad behavior would harm the reputation of the company and its leadership. Instead, it appears that soon after the settlement was announced, top US elected leaders were fawning over this company and its leadership, and rushing to legislate special treatment for it.

Special Treatment from Legislators

Yet soon after these disconcerting revelations that should have shamed Amgen and its leadership, it appears that the company benefited from legislation narrowly crafted mainly just for to suit its interests, and with the aid of allies from both parties within the US government. That story was again just reported by the New York Times. The basics are:

Just two weeks after pleading guilty in a major federal fraud case, Amgen,
the world’s largest biotechnology firm, scored a largely unnoticed coup
on Capitol Hill: Lawmakers inserted a paragraph into the "fiscal cliff" bill that did not mention the company by name but strongly favored one of its drugs.

The language buried in Section 632 of the lawdelays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients.

The provision gives Amgen an additional two years to sell Sensipar
without government controls. The news was so welcome that the company’s
chief executive quickly relayed it to investment analysts. But it is projected to cost Medicare up to $500 million over that period.[That would almost make up for the fine the company had to pay for illegal marketing and to settle kickback charges - Ed]

Amgen, which has a small army of 74 lobbyistsin
the capital, was the only company to argue aggressively for the delay,
according to several Congressional aides of both parties.

But the Times article noted that it was not just the size of its army of lobbyists that did it.

Amgen has deep financial and political ties to lawmakers like Senate Minority Leader Mitch McConnell, Republican of Kentucky, and Senators Max Baucus, Democrat of Montana, and Orrin G Hatch, Republican of Utah, who hold heavy sway over Medicare payment policy as the leaders of the Finance Committee.

In particular, Amgen

has a deep bench of Washington lobbyists that includes Jeff Forbes, the former chief of staff to Mr. Baucus; Hunter Bates, the former chief of staff for Mr. McConnell; and Tony Podesta, whose
fast-growing lobbying firm has unusually close ties to the White House.

Amgen’s employees and political action committee have distributed nearly
$5 million in contributions to political candidates and committees
since 2007, including $67,750to Mr. Baucus, the Finance Committee chairman, and $59,000 to Mr. Hatch, the committee’s ranking Republican. They gave an additional $73,000 to Mr. McConnell, some of it at a fund-raising event for him that it helped sponsor in December
while the debate over the fiscal legislation was under way. More than
$141,000 has also gone from Amgen employees to President Obama’s
campaigns.

What distinguishes the company’s efforts in Washington is the diversity
and intensity of its public policy campaigns. Amgen and its foundation
have directed hundreds of thousands of dollars in charitable
contributions to influential groups like the Congressional Black Caucus and to lesser-known groups like the Utah Families Foundation, which was founded by Mr. Hatch and brings the senator positive coverage in his state’s news media.

Amgen has sent large donations to Glacier PAC, sponsored by Mr. Baucus in Montana, and OrrinPAc, a political action committee controlled by Mr. Hatch in Utah.

And when Mr. Hatch faced a rare primary challenge last year, a nonprofit group calling itself Freedom Path
sponsored advertisements in Utah that attacked his opponent, an effort
that tax records released in November show was financed in large part by
the Pharmaceutical Research and Manufacturers of America, a trade group that includes Amgen.

In some cases, the company’s former employees have found important posts inside the Capitol. They include Dan Todd,
one of Mr. Hatch’s top Finance Committee staff members on health and
Medicare policy, who worked as a health policy analyst for Amgen’s
government affairs office from 2005 to 2009. Mr. Todd, who joined Mr.
Hatch’s staff in 2011, was directly involved in negotiating the dialysis
components of the fiscal bill, and he met with 'all the stakeholders,'
Mr. Hatch’s spokeswoman said, not disputing when asked that this
included Amgen lobbyists.

In addition, a NY Times editorial today pointed out that Mitch McConnell, the Senate Minority Leader, (Republican - Kentucky) who "exerted great influence over the fiscal negotiations and praised the Medicare provisions" presumably including the specific provision that helped Amgen, also has "political and financial ties to Amgen." Furthermore, Senator McConnell's willingness to use taxpayer's money to pay Amgen more seemed to contradict his "public statements [which] usually emphasize the need to cut federal spending on entitlement programs, as they did in Lexington Friday," as reported by WEKU (the National Public Radio Station at Eastern Kentucky University ).

Can We Reform Health Care in the Corporatist States of America?

In summary, Amgen seems to have leveraged its use of former legislative
aides affiliated with both political parties as lobbyists, and its
presumed influence over former employees who are currently legislative
aides, that is, to people who have transited revolving doors in both
directions, to influence policy in its corporate favor. It has also
leveraged its contributions directly to politicians, to political action
committees (PACs), and to non-profit advocacy groups to influence
policy in its direction for this purpose. All this leverage apparently
resulted in continuing government favoritism to a company the government
had just convicted of a crime, and to a company whose actions likely
led to sick and dead patients. Furthermore, legislators who publicly
deplore excess government spending and enlarging government deficits
supported spending more taxpayer money to favor a particular company
that they ought to have shunned.

a disheartening example of how intense lobbying and financial contributions can distort the legislative process in Washington

and second as

a classic example of the power of special interests to shape legislation
and shows how hard it may be to carry out the reforms needed to cut
health care costs.

But it was really much worse than that. This case certainly shows the ongoing coziness between big health care
organizations and government (this time, mainly legislative) leaders,
facilitated by the apparently very common "revolving door" interchange
of influential people between corporate management and government. Note
that this coziness has now become bipartisan. However, this was not merely expensive favoritism. It was hypocritical expensive favoritism that benefited a corporation that ought to have been shamed and shunned for behavior that did not merely cost the government money, but likely harmed patients, sometimes even fatally.

President Theodore Roosevelt condemned malefactors of great wealth. Our current political leaders in both parties seem to put their ties to corporate insiders who work for executives of great wealth ahead of any consideration of what might be good for patients, public health, or the citizenry at large.

So the US now seems to be run by a soft, informal version of corporatism, the system in which government and big corporations overlap and jointly rule the people. Since these days big corporations are run largely without accountability by increasingly rich executives, this ends up meaning government by the oligarchs, for the oligarchs, and of the oligarchs. President Lincoln and President Theodore Roosevelt might be rolling in their graves.

To meaningfully reform health care, it seems like we need to meaningfully reform our entire political system, and both make leaders of health care organizations accountable, and make government again of the people, by the people, and for the people.

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